Monday, October 16, 2006

GBS

Group B strep is a type of bacteria that resides in the birth canal of some women. During delivery of a baby, the bacteria can infect the baby and cause nasty disease - sepsis, pneumonia, meningitis - that can be fatal in some cases, disabling in others. Fortunately, we know how to reduce the risk of a baby getting Group B strep (GBS) infections. During pregnancy we can screen women for the bacteria, and if they have it, treat them with antibiotics, usually penicillin, every four hours from the beginning of labor until delivery.

So I was surprised the other day when I went to the delivery of a mother with GBS in her birth canal to find that she had been treated the night before with two doses of penicillin but then, rather than continuing it until delivery, the obstetrician stopped it, for no good reason. When I found that out in the delivery room I wanted to say "Why would you do a stupid thing like that?" but decided that wouldn't be too professional.

A few minutes later I heard from another obstetrician that the obstetrician in the above case doesn't believe in treating GBS positive women until delivery with antibiotics, seeming to think that the whole thing is a little silly and that two doses are enough. This practice on her part is - how can I put this delicately - absolutely boneheaded. There are some areas in medicine where proper treatment is controversial and different options can be within the standard of care, but this isn't one of them. The Centers for Disease Control, the American College of Obstetrics and Gynecology, and the American Academy of Pediatrics all have official statements and guidelines saying the same thing, that these women should be treated with antibiotics until delivery. It's straight forward, uncomplicated, evidence based medicine. To ignore the guidelines is to invite malpractice suits; should one of the babies develop GBS infection, she might as well just write a blank check to the parents.

I'm not sure why this OB doesn't follow the guidelines. It's hard to believe she is ignorant of them, because it is such a common thing. Also, in other ways she is a consientious obstetrician. Now, though, I have to decide what to do about it. The easiest thing for me would be to refer the case to the OB Quality Assurance committee and let them handle it. That seems a bit heavy handed, though, and I wonder if I should just take the OB aside and talk to her, friend to friend, making sure she knows the guidelines and telling her she should follow them.

But I don't think it will make any difference. For one thing, I can't really say I'm friends with her; she's a bit prickly and doesn't seem to have many friends. Also, she's got a reputation for being a little stubborn. Official guidance from the QA committee might be more likely to change her practices - and keep a baby from getting infected.

19 Comments:

Anonymous Anonymous said...

I would refer her. Heavy handness will save a baby. It is stupid not to give the antibiotics. One dead baby and that practice will change. How could she ever explain to a new mom why she didn't treat and her baby didn't have to die. Stupid stupid stupid

8:31 PM  
Blogger Flea said...

Do statements from professional organizations count against you in malpractice cases if you deviate from them?

I wonder if the folks who write such guidelines know this.

best,

Flea

9:04 PM  
Anonymous Anonymous said...

I've got a question, or rather an observation:

It's known that a woman's GBS status can change from one pregnancy to the next (hence the reason for testing with each pregnancy) and indeed within the same pregnancy. Women on natural-birth forums frequently swap advice on how to skew the odds in favor of a GBS-negative reading, for example by swabbing the area with betadine prior to testing or upping one's garlic and yogurt intakes leading up to the test.

So that begs the question why testing at the 36-week visit is the routine, instead of, say, the 39-week visit, or even weekly the way urine, BP and weight are checked. Is it turnaround time? (I doubt this, as my GBS results in my last pregnancy were known within a few days.)

Just curious....

9:22 PM  
Blogger Lori said...

Interesting doc. I have to say I am pleased to hear your opinion, and have in fact run into other doctors who seem a little dismissive of the treating of GBS. It seems as though there are some in the medical community who don't consider anything a problem unless the numbers get big enough. Tell that to the family whose baby falls on the wrong side of statistics!

A question for you: Do you know if there is anymore evidence about GBS contributing to premature deliveries? At one time I read that was being studied. I tested positive for GBS in my fourth pregnancy and was treated with antibiotics during labor and delivered a healthy baby girl. In my first two pregnancies testing for GBS was not standard protocol yet and so I was not tested. Thankfully, I still delivered two healthy full term babies. However, my third pregnancy ended in the unexplained preterm delivery (23 weeks) of twins, and after I tested positive for GBS in my next pregnancy I wondered if there was a possible relationship?

I recently checked the GBS org. website but didn't find any specific information linking preterm deliveries and GBS.

9:26 PM  
Anonymous colleen said...

Thanks for an interesting post!

Sorry if this is a dumb question, but I wonder if you could explain why the guideline is written the way it is. I know GBS is a potential problem for both mother and baby, but if you are trying to prevent infection, why isn't the duration of treatment based on how long it takes to treat the infection, rather than the highly variable duration of labor? Does the woman who is in labor for 36 hours really need 9 doses and the woman who labors only 6 hours only need 1 dose? I know the baby only benefits until delivery (for obvious reasons) but isn't there an upper bound after which additional doses aren't useful to either mom or baby?

Thanks!

10:33 PM  
Blogger Fat Doctor said...

I say put an anonymous note in her locker.

You could try the direct mano a womano approach followed up by the Big Bad Committee approach if she ignores you. Sounds reasonable.

If I were being boneheaded, I'd appreciate a friendly, private heads up. If I then ignore the heads up, my patients would appreciate an official complaint to the powers that be.

10:40 PM  
Anonymous clobbered@gmail.com said...

I tested GBS positive at 36 weeks. My ObG gave me a course of antibiotics right there and then. By the time I got to labour I had read on the best practice and made sure I asked what was going in my IV so that I could keep track of whether I was getting the dose at the appropriate interval.

I wonder what that doctor would have done had the patient asked (as I would have if I had needed to) "hang on, it has been four hours since my last antibiotic, where is it?"

You are right - why play with fire with something so preventable!

3:01 AM  
Anonymous Anonymous said...

GBS blech. I am a carrier and so I had antibiotics throughout all four labors. I always double checked that I got it, too.

The antibiotics must have crossed the placenta because all four had terrible troubles with thrush.

But as annoying (and painful for me) as thrush is, no way would I risk my baby's life by not taking preventative measures.

3:55 AM  
Blogger sailorman said...

Call QA. Let them know you're trying to prevent the hospital from liability. Let them do their job.

10:02 AM  
Blogger Kelly said...

Definately leaves one to wonder how so many women have babies in their own home and their babies actually survive....

Surely some of these women have GBS.

10:22 AM  
Anonymous Justaminute said...

Interesting post.
I delivered my first 3 kids in Canada. When I had baby #3 I was GBS positive. The doc told me that the guidelines regarding treatment had just changed, and in fact had to leave the room to find out exactly what was supposed to take place. I was given two doses of antibiotics over the course of a 13 hr. labor and my child had an automatic extra day tacked onto his goverment regulated 24hr. stay. I don't know if it is still the policy.

As for Canadian health care...how would you ladies like the 24hr. mandated stay? You get the boot unless you are having some serious issues. It is very common to have to shlepp your 2-3 day old baby back to a nasty emerg. room for simple things that could have been addressed during a little longer stay. And the hospital provides you with nothing for your visit. No pads, diapers, wipes, soap nothing. AND their are no malpractise lawsuits. Period.

When I had baby #4 in the States, I thought I was at a 4-star hotel!

10:23 AM  
Blogger Kelley said...

I'm sitting here stunned. My last pregnancy I tested positive for GBS and when I asked what that was all about they basically told me it was nothing to worry about, like it was some incidental finding or something. Needless to say, I didn't get any antibiotics in labor and delivery. Hmmm...Son went on to NICU for a month with wet lungs. Guess I'm now wondering whether or not that was a coincidence. Oh well. He's doing great now. I honestly never knew there was any risk associated with that. Head spinning and thankful, I guess.

3:16 PM  
Blogger PaedsRN said...

I'm with the estimable Fat Doctor on this one.

Talking to people about things like this is hard. It always feels easier to have someone else do it. Still, I've been in a position where someone has complained about something I did without speaking to me first. I felt robbed of the opportunity to explain or discuss with the concerned party.

I believe professional courtesy demands a direct approach in this sort of situation. It doesn't have to be unpleasant, just "I'm concerned about Baby X's Mom not being treated in the usual way for GBS." If she fobs you off, then it's time for QA.

Finally, and I say this with the respect of a regular reader, be cautious about blogging about her mistakes without her consent... these things have a way of coming back to bite you in the ass.

Good luck!

1:06 AM  
Blogger neonataldoc said...

Thanks, everyone. I didn't realize there would be this much interest in GBS.

Flea, yes and yes. But this guideline is based on good evidence. It's not difficult to follow.

Anon 9:22, I think they test at 36 weeks because it gives the best chance of having the most women having a recent test before they deliver. Lori, good question that I should know the answer to, but I don't, and I haven't had time to look it up. Maybe later. Colleen, they treat for the duration of labor because that's what the studies showed works. You can't really eradicate GBS with antibiotics, but you can keep kids from being infected with it.

FD, the anonymous note idea is tempting. Paedsrn, I appreciate your warning. I really depend on being anonymous.

7:09 PM  
Anonymous Anonymous said...

I am in Canada and tested postive for GBS with my second. I was so worried during delivery and made sure I got my doses.
I had 3 day stays with both my babies and my hospital supplied all the stuff for me and my baby.

11:40 PM  
Anonymous SMND said...

Speaking about GBS & Canada;

My sister had her two GBS labours in 'Teaching Hospital' hospital in Major City and not only did they give her i.v. abx throughout labour, they also gave the babes preventive i.v. abx for the next three days, even though they had no sign of infection. Seemed excessive to me, particularly since they (the babies) ended up with horrible thrush and eczema within days that they are still dealing with several years later.

4:33 PM  
Anonymous Anonymous said...

It amazes me that in this day and age, anyone would "blow off" GBS. I've been a nursery/NICU nurse for a *LONG* time, and will never forget what happened to a co-worker and her baby in the days before moms were screened (1979). The full term, apparently "healthy" infant suddenly became very ill on day 2 of life. It was determined that she had overwhelming GBS sepsis... the neonatologist did everything possible that we had at that time, antibiotics, ventilator, and even tried doing a complete exchange transfusion -- trying anything even remotely possible to save this baby. Sadly, she died on day 4. This is a prime example of WHY testing for GBS -- and TREATING it -- is all important.

7:04 PM  
Anonymous maribeth, cnm said...

I'm late on this conversation but still wanted to add my thoughts...

First off, responsible home birth practitioners DO offer GBS testing and treatment in labor. It's not hard to run an IV at home, and mom does not have to stay hoooked up for long.

NeoDoc, when talking with families about GBS, I recommend you to say "GBS is a bacteria that lives in the bodies of about 1 out of every 3-4 healthy adults". You can talk then about how it gets into the bowel and then, by proximety, the vagina, penis, urethra, etc., and how it only causes problems for select groups of people (very young, very old, immunocompromised). I think we need to keep pregnant women from thinking healthy, normal vaginas are 'diseased' more than any other person's wet dark areas. Seems like a little thing, but know what I mean?

I think multiple antibiotic doses may be found to do as much harm as good, but for now, it's the standard of care and certainly what I follow. I have read a pharmacokinetic or whatever study that showed the best prevention of GBS happened when two doses were received, the second less than an hour from delivery. So that would be doses at 5 hours and 1 hour before birth. Except in case of PROM, there is NO NEED to start antibiotics until active labor. The problem, of course, is hospitals admitting way before real labor, and the unpredictability of the length of labor.

And speaking of totally pointless and harmful practices -- can silly OBs (ok, mostly residents) and L&D nurses PLEASE stop using fetal scalp electrodes without good indication (which is exceedingly rare) in cases of GBS positive? Sure, deadly bacteria, here's a direct portal to the baby... go for it... Most haven't even thought about the connection!! It drives me batty.

12:13 PM  
Anonymous Anonymous said...

All you OBs and Neonatologists are worried about are LAWSUITS! It's not ever about the right treatment for each individual case. What do you do in the event that the mother is severely allergic to all effective antibiotics? Don't you worry about LAWSUIT in that case? I'm so sick of hearing about the medical profession making all-in-one standards based on the potential of LAWSUIT! When on Earth did the beauty of pregnancy/motherhood become a medical ailment/liability? You need to refrain from classifying GBS colonized mothers as "diseased."

9:41 PM  

Post a Comment

<< Home